Direct Debit Suspension Application Request Form
Select your centre
*
Ascot Vale Leisure Centre
Keilor East Leisure Centre
Membership/Program Type
Aquatic/Gym Membership
Swim School Membership
Full Name
*
First Name
Last Name
Email
*
example@example.com
Mobile
*
0400 000 000
Membership Payment Method
*
Direct Debit
Suspend Membership from
*
-
Day
-
Month
Year
Select Start Date (Please pick a future date)
Suspend Membership to
*
-
Day
-
Month
Year
Select End Date (Please pick a future date)
Reason for Suspension
*
I agree to Terms and Conditions
*
By ticking this box I acknowledge that my account will be suspended in line with the T&Cs of my membership. You are entitled to a FREE suspension of up to 6 weeks in total. Regular payments will begin after 6 weeks or your suspension end date if less than 6 weeks
Submit Request
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